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Clinical Case Report
Age: 66
Weight: 64.6 kg
Allergies
Student: Sara Freiheit
NKDA
Gender: Male
Admitting Diagnosis (es) &/or injuries: Chest Pain: Possible
MI, Respiratory Failure, Possible Stroke, GI bleed
Past Medical History (chronic health problems): GERD, GI
ulcer, tonsil cancer S/P chemo, radiation, throat surgery for
cancer, smoker (2 packs a day for 45 years)
Score: ________ / 25 possible points
Choose one medicated drip the patient is receiving such as,
diprivan, dopamine, heparin, insulin or others & calculate the dose
in the appropriate mcg/min, mcg/kg/min, units/hr etc. State if the
medication is within normal, low or high range for the dose. (1 pt.)
This patient was getting diprivan (propofol) at 4 ml/hr. The
concentration of this medication drip is 1000 mg/ 100 ml.
Mcg/min- 666.67 mcg/min … Math: 10,000 X 4 / 60min
Mcg/kg/min- 10.32 mcg/kg/min … Math: 10,000 X 4 / 60 / 64.6
This is a safe dose. It is a low range for the dose. IV ICU range
for sedation in adults is 5-50 mcg/kg/min
**Attach and interpret ECG strip**
Normal Sinus Rhythm
Rhythm: Regular
Rate: 70
P waves: normal, one precedes each QRS, all the same size
PR Interval: 0.12
QRS Complex: 0.08
Describe the pathophysiologic processes that led to in patient’s admission (major admitting diagnosis). Include relationship (s)
of client’s chronic health problems, as relevant. Cite reference used. (2 pts.)
This patient was having a sudden onset of a syncopal episode, right sided weakness and right sided facial droop. The patient was brought en
route to ED in an ambulance when going into cardiac arrest (possible STEMI) at 0848. CPR was performed and a pulse returned at 0904.
Because of this patient’s history as a smoker, it would be of no surprise that a MI would occur. Smokers’ risk factor of an MI is doubled than
that of a non-smoker (Morton & Fontaine, 2009). When a patient experiences an MI, coronary atherosclerosis is usually the cause. With the
amount of smoking this patient has done, it would be no surprise that this patient had a build up of LDL cholesterol, causing a thrombus
formation, resulting in an MI (Morton & Fontaine, 2009). Furthermore, lung damage in this patient would be expected due to the fact that the
bronchioles and alveoli lose their elasticity, impairing oxygen exchange along with cilia no longer being able to remove toxic/harmful
particles, leading to high risks of heart disease or strokes (Morton & Fontaine, 2009). With the patient’s recent family stress, it comes as no
shock that his body may have been compensating to the stress, which causes an increase in oxygen demand, increased heart rate and
increased workload on the already stressed heart, leading to the ischemic event. Cardiac arrest causes a cease in blood flow which prevents
oxygen delivery to the vital tissues and organs. After this, anaerobic metabolism begins. Lactic acid is generated through anarobiosis. When
lactic acid increases, pH decreases and bicarbonate concentration in the body fluids that is caused by the high amounts of lactic acid all
relate back to tissue hypoxia. This acidosis produces an end result of vasodilatation and depression of catecholamine action (Alkaissi, 2010).
Meds – limit to most important medications (6-7 max)
Medications (include – PO/NG/OG, IVP, IVPB, continuous drip): (2 pts.)
Route
Brand/trade name
Use for this patient
Major side effects
IVP
Pantoprazole (Protonix)
This patient was experiencing a
GI bleed from an ulcer at time of
admittance to the hospital. This
medication is used to heal
duodenal ulcers.
Abdominal pain,
diarrhea, hyperglycemia,
hypomagnesemia, bone
fracture, headache
IV
Propofol (Diprivan)
Sedation of the patient while
intubated and on mechanical
ventilator on ICU.
bradycardia, apnea,
hypotension, burning,
pain, stinging, green
urine, abdominal
cramping
OG (PO)
Folic Acid (Folvite)
Stimulates the production of red rash, irritability, difficulty
blood cell function after the GI sleeping, malaise,
bleed;
restoration
and confusion, fever
maintenance
of
normal
hematopoiesis.
Special considerations
for patient
Monitor for increases in
AST, ALT, alkaline
phosphatase and bilirubin.
Dilute with 0.9% NaCl.
(Leeuwen et. al, 2006)
Respiratory rate should be
monitored along with pulse
and blood pressure. Wakeup and assessment of CNS
function should be done
daily during maintenance to
determine minimum dose
required for sedation. Do
not discontinue abruptly,
may cause anxiety and
agitation.
(Leeuwen et. al, 2006)
Assess the patient for signs
of megaloblastic anemia
throughout therapy. Monitor
plasma folic acid levels,
hemoglobin, hematocrit,
and reticulocyte count. Any
antacids should be given at
least two hours after folic
acid.
(Leeuwen et. al, 2006)
PO
Nitroglycerin (Nitrostat)
Increases coronary blood flow by
dilating coronary arteries and
improving collateral flow to
ischemic regions (from MI).
Reduces myocardial oxygen
consumption. Treatment of HF
associated with acute MI.
dizziness, headache,
hypotension, tachycardia,
syncope, restlessness,
blurred vision, nausea,
vomiting
There will be additive
hypotension with
antihypertensives, beta
blockers, calcium channel
blockers, haloperidol or
phenothiazines. This pt was
receiving haloperidol so
hypotension was at
increased risk.
(Leeuwen et. al, 2006)
IV
Dexmedetomidine (Precedex)
Additive sedation for
mechanically ventilated patient.
bradycardia, sinus arrest,
hyptotension, hypoxia,
dry mouth, anemia,
nausea, vomiting, fever
Should not be used for
more than 24 hours.
Monitor ECG and BP
continuously. Assess level
of sedation throughout
therapy. Dose should be
adjusted based on level of
sedation.
(Leeuwen et. al, 2006)
Inhaln
Albuterol (Proventil)
Used as a quick-relief agent for
acute bronchospasm. Pt needed
bronchodilation after extubation
when experiencing trouble
breathing and anxiety.
Nervousness,
restlessness, tremor,
headache, paradoxical
bronchospasm, chest
pain, palpitations, angina,
arrhythmias,
hypertension, nausea,
vomiting, hyperglycemia,
hypokalemia
Assess lung sounds, pulse
and BP before
administration and during
peak of medication. Note
amount, color and
character of sputum.
Monitor pulmonary function
tests. Observe for
paradoxical bronchospasm.
(Leeuwen et. al, 2006)
(___/5 points)
Identify 2 priority NURSING PROBLEMS (10 points for each problem = total 20 points)
1. Ineffective airway related to grossly edematous vocal cords, airway swelling, reintubation trauma and alveoli damange as evidence by
strider, restlessness, fatigue, abnormal trends of ABG’s and increased respiratory rates.
(Include causative factors leading to problem) (1 pt.)

Identify at least 2 measurable patient outcomes/goals related to the problem (relevant subjective and/or objective
assessment and diagnostic & laboratory findings). (1 pt. each)
A. Patient’s lungs will remain clear and pt will show no signs of distress, stridor, dyspnea, wheezing or use of accessory muscles.
B. Patient will demonstrate adequate oxygenation by improving the ABG’s to within normal limits and oxygen saturation will
remain within normal limits.
(Ackley & Ladwig, 2008).
Identify the trend changes of relevant: 1) physical assessment, 2) laboratory data 3) vital signs (as appropriate for the Nursing
Problem chosen) over a 3 day period around the day(s) you cared for this patient. Include a brief explanation of the trend as r/t
pathophysiology. Vent settings must be included if ABGs are trended. (3 pts. total)
Day 1 11/11/12
Day 2 11/12/12
Day 3 11/13/12
Interpretation
Respirations:
Respirations:
Respirations:
The fast rate of respirations once the patient was
Ventilator
Ventilator respirations Ventilator respirations extubated indicates respiratory distress. This also
respirations range
range was a low of 13 were at an average of
suggests that the patient is most likely dyspneic therefore
was a low of 14 and and a high of 24. The
18. After extubation,
needing to breath more times a minute to increase
a high of 20. The
average was 18.
patient’s respirations
oxygenation.
average
ranged from a low of
(LeMone & Burke, 2008)
respirations were
24 to a high of 34.
16.
Arterial Blood
Arterial Blood Gases: Arterial Blood Gases:
The first two days ABG’s were done while the patient was
Gases:
pH: 7.44
pH: 7.53 H
mechanically ventilated. The third day ABG was done
pH: 7.47 H
pCO2: 46.3 H
pCO2: 31.4 L
when the patient had been extubated for one hour. The
pCO2: 48.7 H
pO2: 116.7 H
pO2: 95.3
first day shows that the patient is partially compensated
pO2: 84.8
HCO3: 31.0 H
HCO3: 25.9 H
whereas the second day shows the patient has fully
HCO3: 34.6 H
FiO2: 40
FiO2: 100
compensated since the pH is within normal limits.
FiO2: 40
Vent Settings:
Vent Settings:
However, on the third day, the patient is completely
Vent Settings:
FiO2: 40%
FiO2: 40%
uncompensated. The low pCO2 is not being compensated
FiO2: 40%
TV: 500
TV: 500
by the HCO3. The pCO2 is low because the patient is
TV: 500
Mode: Spont
Mode: Spont
hyperventilating, blowing out all of the carbon dioxide. The
Mode: Spont
PEEP/PSV: 8/10
The nurses’ notes
RASS scores were
consistently -1
throughout the day.
The pt was on
versed until 1145
when it was turned
off. The pt still
maintained a -1
RASS score.
PEEP/PSV: 8/10
Documentation
states that lungs
are CTA and
respirations are
unlabored. No
stridor or accessory
muscle use. A size
8 ET tube in place.
Documentation states
the respirations are
unlabored and lungs
have scattered
rhonchi that improves
with suctioning. No
stridor or accessory
muscle use. A size 8
ET tube in place.
Blood Pressure:
106/66
Heart Rate: 105
Blood Pressure:
124/69
Heart Rate: 110
Oxy Sat.
Oxy Sat.
The pt’s RASS scores
were +2 until
precedex was started
at 1100. RASS
dropped to -2 until
1800 when RASS was
+4. Propofol was
started at 1800 and
pt’s RASS dropped to
-1.
PEEP/PSV: 5 PEEP
loss of this carbon dioxide results in respiratory alkalosis.
(Morton & Fontaine, 2009)
Pt’s RASS before
The patient’s restlessness after extubation indicates that
extubation maintained the patient is not receiving enough oxygen. Low oxygen
at -1. Pt was still on
levels cause restlessness, fatigue and anxiety. On the day
propofol and precedex. that I was caring for the patient, he was relaxed while on
Pt extubated at 1240.
the ventilator in the morning. About a half hour after
At 1330 nurses’ notes
extubation, the patient became very anxious, constantly
state the pt was very
moving around and turning in different directions.
restless, not listening
to commands, leaning
over the side rail and
trying to leave.
Documentation after
The patient’s unlabored respirations while on the ventilator
extubation states
indicate he is under no stress related to breathing. The
respirations are
respirations on the day I cared for the patient became very
labored, use of
labored and the patient was struggling to get air in and out.
accessory muscles,
Stridor was clearly heard. The patient’s accessory muscles
stridor. Reintubation
were being used with each breath. During reintubation, a
with a size 7 ET tube.
size 8 ET tube was initially tried, but unsuccessful due to
airway swelling. The tube was quickly pulled out and lung
sounds of stridor were more intense. A size 7 ET tube was
then put in place. The use of accessory muscles shows
that the patient is needed extra muscle to try to get more
oxygen in. The stridor indicates airway damage, making it
more difficult to breath. A decrease in size of the ET tube
also indicates airway swelling and decreased ability to
breath.
(LeMone & Burke, 2008)
Blood Pressure:
Airway swelling and distress on the patient causes blood
111/65 (before
pressure and heart rate to increase. The pt’s HR and BP
extubation)
were stable on the days leading up to extubation. The high
207/146 (after
anxiety is shown with the increases after extubation.
extubation)
Heart Rate before
extubation: 85
Heart Rate after
extubation: 130
Oxy Sat.
Like blood pressure and heart rate, the oxygen saturation
100
100
100- before extubation
96- after extubation on
2L nasal cannula
will decrease when there is airway swelling and distress.
The oxygen started dropping quickly so the oxygen was
increased from a nasal cannula to a venti-mask at 100%
before reintubated. The patient was never strictly on room
air.
Identify the interdisciplinary team plan for problem interventions. Include Nursing (1.5 pts) and other disciplines (1.5 pts.)
Nursing: Continue to monitor respirations, including the pattern, rate and depth. Assess for signs of distressed breathing, anxiety and
restlessness. Interpret the ABG readings. Monitor oxygen saturation, capillary refill and for signs of cyanosis/pallor. Auscultate lung sounds
for any worsening or adventitious sounds. Suction the patient when hearing adventitious sounds or every two hours. Oral/teeth care every
four hours and head of bed elevated at least 30 degrees to prevent ventilator associated pneumonia.
Respiratory Therapist: Auscultate lung fields for adventitious sounds. Interpret ABG’s and vent settings. Monitor vent tube and equipment,
look for any disconnections or leaks. Monitor vent settings and recommend changes to physician. Albuterol and racemic epinephrine
aerosols to relieve bronchospasms. Inhaled steroids to decrease inflammation and swelling. Monitor the swelling by performing occlusion
tests with weaning parameters such as decreasing FiO2. Suction patient per hospital protocol (q4h) or when hearing crackles/ rhonchi. Assist
the physician with intubation.
Physician: Monitor the vent settings/ make changes. Assess and interpret ABG readings and change the settings based on the ABG’s.
Intubate. Make sure the pH level of the patient remains stable. Order aerosols and inhaled steroids to decrease airway swelling such as
albuterol, bitolterol, metaprotenerol ect.
Physical Therapy: Do range of motion to keep calcium loss from bones at a minimum and to avoid muscle wasting. Mobilizing patient (when
stable) to chair will decrease swelling.
What are the potential complications for this patient related to this nursing problem and treatment interventions? (1 pt.)
One potential complication for this patient would be the CO2 continually decreasing. When CO2 decreases, it causes the blood to be more
viscous. When this happens, it causes more workload on the heart and harder pumping is needed. This is not going to be adequate on a
heart that is already struggling due to an MI. A low pH usually accompanies a low CO2. When a patient hyperventilates such as this patient,
the pH of the stomach and gut becomes lower. This causes a more likely chance for gastritis, ulcers and stones (Morton & Fontaine, 2009).
This pt has already had ulcers, so the likelihood of developing another is already greater as it is. Another complication is the fact that this
patient was reintubated. Reintubating a patient causes more vocal damage and airway swelling, especially considering an ET tube size that
was too big was first tried before removing it. Being on a trach and ventilator because of the inability to maintain his own oxygenation
increases this patient’s risk of ventilator associated pneumonia, aspiration, pneumothorax, decreased cardiac output and much more (Morton
& Fontaine, 2009). Because this patient had a swollen airway, he will be put on steroids to get the swelling to go down before extubation
again. The side effects of steroids include but are not limited to loss of calcium from the bones, fluid retention and increased blood sugar
(Leeuwen et. al, 2006). This patient is on bed rest while on the ventilator, so he is already experiencing loss of calcium from the bones. He
also has a heart that is not working as efficiently, causing fluid build up. Also, he is a diabetic with high blood sugar. All of these are only
going to be worsened by being on steroids. Due to all of the complications of a trach and peg, there is an increased hospital stay and a
permanent trach may be needed for a patient who is unable to be weaned off a ventilator. This creates a worry of an inability to return home,
pain, distress and of course the risk of death.
2. At risk for bleeding/hemorrhage related to GI ulcer as evidence by decreased hemoglobin and hematocrit, black, tarry stools, pallor,
hypotension and decreased urine output.
(Include causative factors leading to problem) (1 pt.)

Identify at least 2 measurable patient outcomes/goals related to the problem (relevant subjective and/or objective
assessment and diagnostic & laboratory findings). (1 pt. each)
A. Patient’s H&H and platelets will be within normal limits.
B. Patient will have an absence of tarry stools and an absence of signs of gastric bleeding.
C. Patient’s urine output will be within normal limits (about 1500 ml in 24 hours, 50-60 cc in one hour, or about 1 ml/kg/hr)
D. Patient will have a stable blood pressure above 90 mmHg systolic.
(Ackley & Ladwig, 2008).
Identify the trend changes of relevant: 1) physical assessment, 2) laboratory data 3) vital signs (as appropriate for the Nursing
Problem chosen) over a 3 day period around the day(s) you cared for this patient. Include a brief explanation of the trend as r/t
pathophysiology. Vent settings must be included if ABGs are trended. (3 pts. total)
Day 1 11/11/12
Day 2 11/12/12
Day 3 11/13/12
Interpretation
Hemoglobin: 11.1 L Hemoglobin: 11.4 L
Hemoglobin: 11.0
This patient was experiencing a GI bleed on the day of
Hematocrit: 32.2 L
Hematocrit: 31.9 L
Hematocrit: 34.2
admittance to the hospital. On 11/6 the patient’s
hemoglobin was 9.6 and hematocrit was 31.1. Therefore,
the numbers have increased since his admittance, which
means he is trending in the right direction. This patient
received packed RBC’s for three days. The low hemoglobin
count from the GI bleed decreases the amount of oxygen
that can be carried to muscles and organs. The low
hematocrit is from the loss of blood, which decreases the
total RBC volume.
(LeMone & Burke, 2008)
No stool passage
Nurses’ Notes
The patient had a
When the patient was admitted on the 5th of November, he
on 11/11/12.
indicate the patient
bowel movement. The
had black stool which is indicative of a GI bleed. The
had a bowel
stool was dark brown
patient’s bowl movement descriptions and consistencies
movement with dark
and liquidy.
were not documented every day, but the patient had a
brown stools.
bowel movement while I was at clinical. The stool did not
appear black, just a dark brown color. This indicates the GI
bleeding has stopped, at least to the point of not seeing it
Balance of intake
and output: -736
Balance of intake and
output: -233
Balance of intake and
output: -701
Blood Pressure:
106/66
Blood Pressure:
124/69
Blood Pressure:
111/65
in the stool anymore.
On 11/5/12 the patient had an intake of 1155 and output of
670, with a balance of positive 485. A complication of a GI
bleed includes a decreased urine output, therefore
resulting in positive balances. Seeing as how the past
three days the patient has had a negative balance, shows
that the urine output has increased and he is no longer
experiencing this complication as a result of a GI bleed.
(LeMone & Burke, 2008)
On 11/5 the patient’s blood pressure averaged to be about
66/35 mmHg. This is also a complication of a GI bleed. The
drop in blood volume is what produces the decreased
blood pressure. Now that the blood volume has been
increased since the GI bleed has ceased, the blood
pressures are increasing as seen on the left.
(LeMone & Burke, 2008)
Identify the interdisciplinary team plan for problem interventions. Include Nursing (1.5 pts) and other disciplines (1.5 pts.)
Nursing: Monitor intake and output. The balances should be as close to even as possible. Blood pressures should be monitored and a drastic
increase or decrease in it should be reported to the physician. Monitor the stool for a black color, indicating GI bleed. Monitor hemoglobin
and hematocrit results and report abnormalities to the physician. Watch for changes in skin color, temperature, moisture or slow capillary
refill which shows a decreased cardiac output, another complication of a GI bleed. Measure gastric output hourly if on a low suction. Maintain
two peripheral intravenous lines for fluid and blood transfusions. Replace gastric drainage with balanced electrolytes.
Physician: Determine complications/treatments for results of blood pressure, urine output, H&H and gastric output. Prepare for surgery or
endoscopy. Monitor pH. Have GI consult with an EGD. Avoid anticoagulants if the patient is bleeding or monitor the use of them. Ordered
three blood transfusions over a three day period (5th, 6th, 7th of Nov.) along with daily medications of folic acid and vitamin B12.
Dietary: Ensure adequate balance of nutrition
What are the potential complications for this patient related to this nursing problem and treatment interventions? (1 pt.)
Complications of this patient related to the problem and treatment interventions are endless. Like discussed early, the loss of blood volume
decreases H&H which decreases oxygenation to tissues, decreases urine output and decreases blood pressure. Also, with renal failure and
limited or inadequate restoration of circulating volume, initiation of inflammatory changes can be expected. Shock is a result and it causes
neutrophil activation and liberation of adhesion molecules, which promote binding of neutrophils to lung and vascular endothelium. Shock
results in acidosis and pain, weight loss and malnutrition are likely to happen. Capillary leak is then initiated in the lungs which results in
respiratory distress syndrome. The liver is damaged due to microischemia (MI) which means the liver is not able to process and metabolize
drugs and chemicals (Garrioch, 2004). An impaired fuel delivery to the heart and brain is also a major concern. This would cause a decrease
in level of consciousness and death would be a possibility. Continual treatment with folic acid to increase RBC production can cause the
patient to be confused and develop a rash and/or fever.
References:
Ackley, B.J., Ladwig, G.B. (2008). Nursing diagnosis handbook: an evidence-based guide to planning care. (8th ed.) Philidelphia: Mosby Elsevier
Alkaissi, A. (2010). What is cardiac arrest? An-Najah National University.
A.M. Van Leeuwen, T.R. Kranpitz & L.S. Smith (Eds.) (2006), Davis’s comprehensive handbook of laboratory diagnostic tests- with nursing implications
(version 9.0.8/2008.05.12) [Skyscapes Constellation Plus version].
Garrioch, M. (2004). The body’s response to blood loss. Blackwell Publishing Ltd. Vox Sanguinis (2004) 87 (Suppl. 1), Pg. 74–76.
LeMone, P., Burke, K. (2008). Medical-Surgical Nursing: Critical Thinking in Client Care. (4th ed.). New Jersey: Pearson Prentice Hall.
Morton, P.G., Fontaine, D.K. (2009). Critical care nursing: a holistic approach. (9th ed.). Philadelphia: Lippincott Co.